|Year : 2011 | Volume
| Issue : 4 | Page : 129-131
Intravesical pressure: A new prognostic indicator in congenital diaphragmatic hernia
Mohan K Abraham, Naveen Viswanath, P Ramakrishnan, S Bindu, P Kedari, Aisha Naaz, Lukman O Abdur Rahman, Abdulrasheed A Nasir, Sharon Mohan, R Shivji, P Sasidharan
Department of Pediatric Surgery and Neonatology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
|Date of Web Publication||31-Oct-2011|
Mohan K Abraham
Department of Paediatric Surgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: To evaluate the usefulness of intravesical pressure as a prognostic indicator in congenital diaphragmatic hernia. Material and Methods: In 25 cases, bladder pressure was measured intraoperatively during repair. Results: Cases were divided into three groups according to the intravesical pressure. Group 1: pressure <10 cm (n.9), Group 2: 10-15 cm (n.11) and Group 3: >15 cm (n.5). Number of ventilated days was tabulated against these groups. Median number of ventilated days for Group 1, with the lowest pressure, was 3 days, while that for Group 2 was 5 and for Group 3, with the highest pressure, was 10 days. This was significant, with a P-value of 0.016. Conclusion: Measurement of intravesical pressure is a reliable prognostic indicator in newborns with congenital diaphragmatic hernia. It also helps in predicting postoperative ventilatory requirement.
Keywords: Bladder pressure, congenital diaphragmatic hernia, intra-abdominal pressure, pulmonary hypoplasia
|How to cite this article:|
Abraham MK, Viswanath N, Ramakrishnan P, Bindu S, Kedari P, Naaz A, Abdur Rahman LO, Nasir AA, Mohan S, Shivji R, Sasidharan P. Intravesical pressure: A new prognostic indicator in congenital diaphragmatic hernia. J Indian Assoc Pediatr Surg 2011;16:129-31
|How to cite this URL:|
Abraham MK, Viswanath N, Ramakrishnan P, Bindu S, Kedari P, Naaz A, Abdur Rahman LO, Nasir AA, Mohan S, Shivji R, Sasidharan P. Intravesical pressure: A new prognostic indicator in congenital diaphragmatic hernia. J Indian Assoc Pediatr Surg [serial online] 2011 [cited 2017 Dec 13];16:129-31. Available from: http://www.jiaps.com/text.asp?2011/16/4/129/86864
| Introduction|| |
Congenital diaphragmatic hernia is a common problem in pediatric surgical practice, with an incidence of 1:2500.  Although the pathological anatomy is the same, the survival rates among patients vary. This is mainly because of the associated pulmonary hypoplasia, which varies from patient to patient. There are many prognostic indicators like oxygen index and lung to head ratio, and anatomical factors like right-sided hernia that predict the overall survival , and help in selection of patients for surgery. But, these do not predict the postoperative ventilatory requirement of the patient. Our aim was to find an indicator that will predict the postoperative course once other indices have predicted survival and fitness for surgery.
The more the herniation of bowel into the chest and the earlier it occurs the more severe will be the pulmonary hypoplasia and the lesser the development of the abdominal cavity. This means that once the hernial contents are reduced into the abdomen, a smaller abdominal cavity will have higher intraabdominal pressure. Measurement of abdominal pressure via vesical pressure will indicate the severity of pulmonary hypoplasia and also the ventilatory compromise due to pressure on the contralateral diaphragm from the reduced bowel leading to its reduced movements. These will predict the postoperative course.
| Materials and Methods|| |
Twenty-eight consecutive cases that underwent repair of diaphragmatic hernia from Jan 2006 to Nov 2009 were studied prospectively. Three cases were excluded from the study. One case had prolonged ventilation due to seizures that was not controlled with medication. In the other two infants, the abdomen could not be closed because the underdeveloped abdominal cavity not being able to accommodate the reduced bowel. These two cases were managed with creation of ventral hernia.
All were newborns. Age after birth ranged from 2 to 5 days, with a mean of 2.68 days. Weight varied from 1.5 to 3.9 kg, with a mean of 2.88 kg. After initial resuscitation, all babies were ventilated for a period ranging from 1 to 23 days, till the pulmonary vasculature stabilized and patients were free of episodes of pulmonary hypertension and FIO 2 requirement came to less than 70%, before they were taken up for surgery.
In the operating room, the patients were catheterized with a 6F infant feeding tube. The abdomen was opened through a left upper abdominal transverse incision. The diaphragmatic defect was identified, contents were reduced and the defect closed. The abdominal wall was stretched to increase the volume of the abdominal cavity. The peritoneum was closed. The bladder pressure was measured as recommended by the World Society for Abdominal Compartment Syndrome (WSACS).  The urinary bladder was emptied. Normal saline was instilled into the bladder with a volume of 1 ml/kg. The feeding tube was held vertically up and the height of the column of saline from midaxillary line at the level of iliac crest was measured at the end of expiration. All pressures were noted in centimeters of saline. (1.36 cm of saline equals 1 mm of mercury).
| Results|| |
The 25 cases enrolled for the study were divided into three groups according to the bladder pressure. Group 1 had nine cases with a pressure of or less than 10 cm of saline (7.4 mmHg). Group 2 had 11 cases with pressures ranging from 10 to 15 (7.4 to 11 mmHg) and Group 3 had five patients with pressures exceeding 15 cm (11 mmHg) of saline.
Abdominal pressure was tabulated with the number of ventilated days. Both were parallel when plotted as a line graph showing correlation, while postnatal age and weight did not show any correlation with the number of days of ventilation [Figure 1]. Bar graph showed that higher the bladder pressures, longer the ventilatory requirement [Figure 2]. Number of ventilated days was tabulated against the three groups. Because values had a wide range, median was taken instead of mean and the Kruskal-Wallis test was used to calculate the significance. SPSS 11 was used for the statistical analysis. Median for Group 1 was 3 days of ventilation while that for Group 2 was 5 and Group 3 was 10 days. This was significant, with a P-value of 0.016. However, birth weight or gestation did not correlate with the ventilatory requirement.
|Figure 1: Abdominal pressure paralleled the number of days of ventilation|
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We had three deaths in this study, all of which occurred in Group 3. Two children died of necrotizing enterocolitis and multiple bowel perforations. Both had laparotomy and stoma, but died of fulminant sepsis. The third child died of germinal matrix bleed and seizures.
| Discussion|| |
Postoperative ventilatory requirement will be determined by the combined effect of pulmonary hypoplasia and reduced movement of the contralateral diaphragm due to increased intra-abdominal pressure. Oxygen index and other indices measure pulmonary hypoplasia while intra-abdominal pressure indicates both the pulmonary hypoplasia as well as the diaphragmatic mobility.
The pressures were measured after the closure of the peritoneum. It was performed in supine position as recommended by WSACS. This was done as, in the event of high pressures indicating abdominal compartment syndrome, the peritoneum could be easily reopened and closure of the abdomen could be done by either creating the ventral hernia or silo. We had to perform this in two cases that were excluded from the study.
WSACS has defined intra-abdominal hypertension (IAH) as pressures exceeding 12 mmHg.  In Group 3, only one patient had an IAH of 12.5 mmHg. None of the patients had oliguria or organ dysfunction, which would have indicated IAH. Therefore, IAH cannot account for the variation in ventilatory requirement. Ventilatory requirement had no relation either to the gestational age or birth weight. The intra-abdominal pressure thus reflected the combined effect of pulmonary hypoplasia and reduced movement of the contralateral diaphragm on the postoperative course of the patient. Measurement of bladder pressure by measuring the height of the saline column is simple and easy to perform, and has less chances of technical error as compared with measurement with a transducer. Bladder pressure is an intra-operative index and cannot be used for the selection of patients for surgery but can predict the postoperative ventilatory requirement.
Intra-abdominal pressure, after reduction of hernial contents and closure of peritoneum, is a reliable indicator of postoperative ventilatory requirement in newborns with congenital diaphragmatic hernia. This will help in planning the postoperative management and briefing the parents.
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[Figure 1], [Figure 2]